Clinical Context

Mood disorders are one of the most important comorbid conditions among patients with dementia, but what are the prevalence rates of symptoms of depression, anxiety, and apathy among adults with dementia, and does prevalence change as patients advance through different stages of dementia? Leung and colleagues answered these questions in a systematic review and meta-analysis. Their results were published in the April 27, 2021 issue of International Journal of Geriatric Psychiatry.^[1]

The review netted 20 studies, which included a total of nearly 6000 adults. The prevalence rates of both depression and anxiety in mild, moderate, and severe dementia were 38%, 41%, and 37%, respectively. Apathy was more common and reported by 54%, 59%, and 43% of patients with mild, moderate, and severe dementia, respectively.

Overall, there was not a significant difference in the prevalence of depression, anxiety, or apathy in comparing the stages of dementia. The authors did not perform other subgroup analyses to establish other risks for these disorders.

Both mood disorders and dementia can contribute to a higher risk for suicide. The current study by Alothman and colleagues evaluates dementia as a risk factor for suicide.

Study Synopsis and Perspective

Three subgroups of patients are at increased risk for suicide after a diagnosis of dementia: a finding that paves the way for more targeted suicide risk assessment and intervention, new research suggests.

In a large population-based, case-control study, results showed an increased risk for suicide among persons with younger-onset dementia, defined as being diagnosed before age 65 years, persons diagnosed within the previous 3 months, and persons who also had mental illness.

"Doctors should be aware that these groups are at increased risk and consider early signposting/referral to appropriate mental health services," senior investigators Charles Marshall, MRCP, PhD, clinical senior lecturer and honorary consultant neurologist, Wolfson Institute of Population Health, Queen Mary University of London, United Kingdom, told Medscape Medical News.

"Perhaps more importantly, the design and remuneration of dementia diagnosis services need to take account of the importance of providing adequate resources for postdiagnostic support and risk assessment," Marshall said.

The findings were published online October 3 in JAMA Neurology.^[2]

The researchers reviewed the electronic medical records from 2001 to 2019 for approximately 594,000 adults. Among the 4940 adults diagnosed with dementia, 95 (1.9%) died by suicide.

There was no overall significant association between a dementia diagnosis and suicide risk (adjusted odds ratio [aOR] 1.05 [95% CI: 0.85, 1.29]); however, compared with adults who had not been diagnosed with dementia, suicide risk was significantly increased among peers diagnosed with dementia before age 65 years (aOR 2.82 [95% CI: 1.84, 4.33]).

The risk was more than 2-fold higher within the first 3 months of diagnosis (aOR 2.47 [95% CI: 1.49, 4.09]) and in persons with comorbid psychiatric illness (aOR 1.52 [95% CI: 1.21, 1.93]).

Among adults younger than 65 years who were within 3 months of diagnosis, suicide risk was nearly 7 times higher than among their peers without dementia (aOR 6.69 [95% CI: 1.49, 30.12]).

Adults with dementia who died by suicide were significantly younger at their time of death than peers with dementia who died of other causes (median age, 79.5 years vs 87.9 years).

"Given the current efforts to improve rates of dementia diagnosis, these findings emphasize the importance of concurrent implementation of suicide risk assessment for the identified high-risk groups," the investigators wrote.

Marshall noted that the elevated suicide risk after a dementia diagnosis in these subgroups may be due to a combination of the stress of diagnosis and neurodegenerative effects of the disease.

"A dementia diagnosis can be devastating, and many patients have fears for their future quality of life and fears that they may be a burden to those around them. In addition, we know that depression, anxiety, and social isolation can be early symptoms of Alzheimer's disease; and all of these may increase suicide risk too," Marshall said.

Commenting on the findings for Medscape Medical News, Beth Kallmyer, MSW, vice president of care and support for the Alzheimer's Association, said this large study is one of few that have examined the "devastating" psychological effects of being diagnosed with dementia.

For example, a study published last year showed that adults older than 65 years who were diagnosed with Alzheimer disease were twice as likely to die from suicide than older adults who did not have dementia, as reported by Medscape Medical News.

Receiving a diagnosis of Alzheimer disease at an early age is "rare, unexpected, and overwhelming -- making it very difficult to accept. The worry or fear about being a burden to family members can lead to thoughts of suicide," said Kallmyer, who was not involved with the research.

"Individuals diagnosed with younger-onset Alzheimer's face additional challenges because they are often raising families and taking care of their own parents. Losing their ability to work is especially devastating since they are often in the prime earning years," she said.

Kallmyer noted that it is common for individuals living with dementia to have suicidal thoughts, but having suicidal thoughts and taking action on them is very different.

"The signs to look for in a person living with Alzheimer disease are the same as any other situation: talking about wanting to die, fear of being a burden, feeling hopeless and helpless, withdrawing from friends and family, changes in sleeping and eating habits," she said.

She added that one of the most important things a healthcare provider can tell someone facing a dementia diagnosis is that they are not alone and that support is available.

The Alzheimer's Association has support groups and disease education programs for individuals living with Alzheimer disease, Kallmyer noted.

The study received no specific funding. Marshall and Kallmyer have reported no relevant financial relationships.

Study Highlights

• The case-control study used national databases in England, which contained information on outpatient records, inpatient records, and death records.
• The main study variable was dementia diagnosed after age 45 years. Dementia was established through diagnosis codes or the receipt of antidementia drugs.
• Cases of suicide were matched with ≤ 40 control patients who did not commit suicide. Matches were drawn from the same practice site as cases.
• The main study covariates were sex and age, and researchers also accounted for time since dementia diagnosis and the presence of mental health disorders in their analysis.
• 594,674 patients provided data for study analysis. 14,515 of these patients (2.4%) died of suicide. The median age of all patients who died of suicide was 47.4 years, and 74.8% were male.
• 4940 patients had a diagnosis of dementia, and 1.9% of patients with dementia died by suicide. The median age of patients with dementia who committed suicide was 79.5 years, which was younger than the average age of death among other patients with dementia (87.9 years).
• There was a significant difference in the median age of diagnosis of dementia in the cohort who committed suicide vs persons who did not (76.1 vs 80.5 years, respectively).
• The aOR for suicide associated with dementia was 1.05 (95% CI: 0.85, 1.29).
• The respective aOR among patients diagnosed with dementia before age 65 years was significant (2.82 [95% CI: 1.84, 4.33]). Recently diagnosed dementia within the past 3 months was also associated with a higher risk for suicide (aOR 2.47 [95% CI: 1.49, 4.09]).

Figure. Factors That Increase Suicide Risk in Patients With Dementia

• Having a diagnosis of dementia in the past 3 months and being aged < 65 years at the time of diagnosis was associated with an aOR for suicide of 6.69 (95% CI: 1.49, 30.12).
• The higher risk for suicide endured for a year among persons diagnosed with dementia before age 65 years, but the risk associated with a recent diagnosis of dementia was not as durable.
• Interestingly, the diagnosis of dementia without a concomitant mental health diagnosis was associated with a lower risk for suicide, but concomitant diagnoses of dementia and a mental health disorder were associated with a higher risk for suicide.
• The specific cause of dementia did not affect the risk for suicide, and the use of medications to treat dementia may have had a protective effect against suicide.
• Patient sex did not significantly affect the relationship between dementia and the risk for suicide.

Clinical Implications

• In a previous study by Leung and colleagues, the prevalence rates of both depression and anxiety in mild, moderate, and severe dementia were 38%, 41%, and 37%, respectively. Apathy was more common and reported by 54%, 59%, and 43% of patients with mild, moderate, and severe dementia, respectively. Overall, there was not a significant difference in the prevalence of depression, anxiety, or apathy in comparing the stages of dementia.
• The current study by Alothman and colleagues failed to find a higher risk for suicide associated with dementia, although dementia diagnoses within the prior 3 months and among persons younger than age 65 years were significantly associated with a higher risk for suicide.

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